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EDITORIAL
Reach Out and Read: evidence based approach to promoting
early child development
Barry Zuckermana and Aasma Khandekarb
a
The Joel and Barbara Alpert Professor and Chair, The
Department of Pediatrics, Boston University School of
Medicine and Boston Medical Center and bDivision of
Developmental and Behavioral Pediatrics, Boston
University School of Medicine and Boston Medical
Center, Boston, Massachusetts, USA
Correspondence to Barry Zuckerman, MD, Boston
Medical Center, 771 Albany Street, Dowling 3509
South, Boston, MA 02118, USA
Tel: +1 617 414 7424; fax: +1 617 414 3833;
e-mail: [email protected]
Purpose of review
This article describes the evidence about why reading aloud to children is important to
help them develop the language and early reading skills necessary for school readiness.
Recent findings
This information supports the value of Reach Out and Read; physicians advising parents
to read aloud.
Conclusion
Reach Out and Read should be implemented in health care sites serving low-income
children.
Current Opinion in Pediatrics 2010, 22:000–000
Keywords
child development, primary care prevention, Reach Out and Read
Curr Opin Pediatr 22:000–000
ß 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
1040-8703
Introduction
In the 1980s, clinical observation revealed that many
parents in the primary care clinic at Boston City Hospital
were not reading to their young children and did not have
children’s books at home. Parents gave multiple reasons,
including no children’s book stores in the inner city, no
experience – their parents did not read to them, especially those raised in other countries – the high cost of
books, or that reading was not a pleasurable experience.
In response, in 1989 a few doctors started giving their
patients books and their parents advice on reading aloud
[1]. Nineteen years later, in 2008, doctors in over 4000
clinics and practices gave approximately 5.7 million new
books and reading aloud advice to over 3.5 million
children in all 50 states. Reach Out and Read anticipatory
guidance moved beyond traditional parent education of
telling parents what to do, to creating real time learning
experiences by modeling developmentally appropriate
‘reading’ strategies (e.g. pointing, naming, asking questions) and then giving a book to take home to implement
the recommendation. This paper will review the problem
being addressed by Reach Out and Read, the contribution of the interplay of early experience and brain
development to language and early reading, the importance of parents reading aloud, and the opportunity for
pediatricians to impact this critical activity.
a fifth grade level, which is inadequate to cope with
everyday demands. Minorities are also overrepresented
in this group; 39% identified themselves as Hispanic and
20% identified themselves as Black [2]. However, this is
just the tip of the iceberg; an additional 30% of adults
cannot read at an eighth grade level. These figures have
important health, economic and social consequences.
The problem
This adult problem, like many others, starts in childhood;
approximately 35% of disproportionately low-income
American children lack the basic language skills needed
to learn to read when they enter kindergarten, ultimately
leading to school failure, truancy, and drop outs, which in
turn leads to higher risk for early pregnancy, drug and
alcohol use, illegal activity and poor health literacy. One
of the most studied and important contributors to reading
readiness is exposure to words and subsequent vocabulary [3]. Large social class differences are reported in
children’s exposure to oral language and their vocabularies. Hart and Risley [4] reported that, at the age of
3 years, children in professional families heard an average
of 2153 words per hour whereas children in working-class
families heard 1251 words per hour and children in
welfare families heard only 616 words per hour. This
led to enormous differences in children’s vocabularies. At
age 3, children in professional families had an observed
cumulative vocabulary of 1100 words, while children in
working class families had an observed vocabulary of
750 words and children in welfare families had an
observed vocabulary of just above 500 words.
Low literacy among American adults is a severe and
pervasive problem in the United States. Approximately
20% of Americans are functionally illiterate, reading below
Parents who were professionals not only talked more, but
they also used more complex words and provided a
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DOI:10.1097/MOP.0b013e32833a4673
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2 Invited commentary
greater richness of nouns, modifiers and verbs. They also
spent a lot of time and effort asking their children
questions, and affirming and expanding their responses
[4]. Welfare parents, on the contrary, spent less time
talking and used more imperatives and prohibitions; ‘look
at that’, ‘do not do that’, etc.
Children acquire about 860 words per year from age one
to the end of second grade, or about 2.4 words per day,
resulting in 6000 words. Unfortunately, the variability is
significant; the bottom 25% of children average only
approximately 1.6 words per day, resulting in only having
4000 words by the end of the second grade. Low-income
children are also much less likely to be exposed to these
new and unusual words compared with frequently used
and common words, which foster later language development [5].
Although reading aloud to young children promotes
language and prereading skills [6,7], a recent national
survey in the United States found that 16% of parents of
children aged 3 years do not read at all with their children,
and 23% do so only once or twice a week [8]. Reading is
even less among low-income children or those whose
mothers have less than a high school education. A typical
middle-class child enters first grade having been read to
for approximately 1000 h, compared with 25 h for lowincome children [9]. Children starting school with lower
levels of experience with books and reading become
poorer readers [10].
Understanding the role of brain development
in reading aloud
Much of the new understanding of the developing brain
in the early years of life emphasizes the translation of
early experiences into neuronal connections, which in
turn may influence later child development. Children are
born with all their neurons already formed. However,
synapses between these neurons are in large part established and elaborated after birth, reaching a peak by
3 years of age. Half of these synapses are lost by age
15 through the ‘pruning’ of unused neural connections
due to lack of environmental exposure, whereas those
synaptic pathways that are stimulated are strengthened.
At birth children’s brains are sensitive to all language,
especially in the first 6 months; newborns and even
fetuses can discriminate their mother’s voice from the
voice of a stranger [11,12]. Infant-directed speech
increases blood flow to the frontal lobe of the brain
[13]. Infants progress beyond voice discrimination to
discriminating among sounds of almost any language
before 6 months. By 6–12 months, the brain begins to
become more sensitive to the sounds of their home
language, and over time they can lose the ability to
discriminate sounds in other languages if they are not
exposed to them [14]. The synaptic connections are
strengthened by the sounds heard and are lost (pruned)
when not exposed. For example, individuals who have
spent their first decade hearing Asian languages in which
the phonemes r and L are interchangeable are unable to
differentiate those sounds [15]. Positron emission tomography (PET) scans have shown that the r and L sounds
are decoded in separate parts of the brain of an Englishspeaking person, but these sounds are processed in the
same part of the brain of someone in whose native
language these phonemes are not differentiated [16].
The evolution of the ‘reading brain’ required brain wiring
to go beyond processing written symbols that represent
concrete objects, such as animals or fire, to strengthening
previously unused connections to process letters (circles
and lines) to meaningful symbols with associated sounds
[17]. This evolutionary step of brain development is
illustrated in an imaging study showing limited neural
activity in response to seeing a pseudo-word such as
MBLI. However, when presented with the same letters
that make up a real word (LIMB), maximal activity is
elicited in the visual area, leading to stimulation of a
whole network of processes and regions in the temporal
lobe (auditory and language-based processes including
comprehension), parietal lobe (language) and association
areas that take up half the cortex [18].
Another example of the developmental nature of experience and brain development is the difference in the ease
of acquiring a second language in the early years compared with adolescence. If a child learns two languages in
early childhood, he will speak both languages with sophisticated grammatical construction and accent. If a second
language is learned in high school or college, even proficient speakers generally do not have as complete a
mastery of grammatical construction or accent as early
speakers or native speakers. Furthermore, PET scans
have shown that, when a child grows up learning two
languages, all language activity is found in the same place
in the brain. Children who learn a second language at a
later age show two foci of language activity.
One interpretation is that learning a second language
later takes more effort than when language is learned at
its developmentally optimal time, because it is processed
and wired in a different place [19]. Acquisition of
language in early childhood is captured by the expression
that language is caught not taught. Acquisition of another
language in later childhood or older is different and may
rely much more heavily on memorization of words, rules
of grammar or other processes.
Reading aloud to children beyond infancy plays an
important role in preparing children to read. It is a
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Reach Out and Read Zuckerman and Khandekar 3
pleasurable activity that promotes the development of
language and other emergent literacy skills [20–23],
which in turn helps children get ready for school
[20,22]. Children learn basic book skills; recognizing
letters, understanding that print represents the spoken
word, learning how to hold a book, turning the page and
starting at the beginning [24–26]. Reading aloud is also
associated with learning print concepts [25], exposing
children to written language, which is different from
spoken language [27], as well as story structures (e.g.,
stories have a beginning, middle and end) and literacy
conventions such as syntax and grammar, which are
essential for understanding texts [28].
compared with their white counterparts. They also have
fewer reading materials in the home. Hispanic families,
however, engage their children in ‘explanatory talk’
during dinner or stories [38].
Reading aloud also promotes phonological awareness (the
ability to manipulate the sounds of spoken language
[9,29]) necessary for learning to read. Many alphabet
books, for example, contain the letter name accompanied
by objects whose names begin with the critical sound
such a D, shown with pictures of dog, deer, and doctor.
When parents stress the initial sounds in these words
when reading with their children, they are teaching
awareness of initial phonemes or shared phonemes across
words [30]. There are important differences in letter
knowledge between children from middle-class and
lower-class families. Four-year-olds from middle-class
families know an average of 54% of the letter names
and 5-year-olds know 85% of the letters [31] compared
with low-income children, who know on average about
four letters at age 4 and who learn an additional five while
enrolled in Head Start [30,32]. Children learn the meaning of new words during bookreading interactions with
their parents [33].
The opportunity for pediatricians
The most effective reading style, dialogic or interactive
reading [34], which involves asking questions, providing
feedback and letting the child become the narrator of the
story, can be taught [35]. Children whose parents received
training in dialogic reading had significantly better expressive language skills postintervention 9 months later than
children whose parents did not use dialogic reading [36].
The effectiveness of reading aloud interventions is systematically reviewed in a recent report from the National
Early Literacy Panel (NELP) [37].
Culture influences parents’ attitudes about literacy and
reading aloud to children. In some cultures, reading is an
activity of teachers when a child enters school and not
part of parenting. Older siblings, however, may read
books to younger children. Even where parents do not
read to their children, they expose children to language
by singing songs, reciting nursery rhymes and other
rhyming games and story telling, talking and conversation, especially at meal time. For example, Spanishspeaking parents tend to engage in fewer home-learning
activities such as reading or singing to their children
Oral storytelling in African–American homes is more
common than reading aloud and is used to preserve a
cultural identity [39,40]. Also when reading, low and
middle socio-economic status African–American mothers
label pictures for the child to imitate, and ‘stick to the
text’, as opposed to white middle-class mothers, who
frequently ask questions about the text [41].
Reach Out and Read is based on over 30 years, progressive
emphasis in pediatrics on child development and behavior.
The reframing of the scope of pediatric practice under the
construct of ‘new morbidities’, the influential 1987 report
from the Task Force on Pediatric Education [42,43] and
influential leadership of Julius Richmond, MD, T. Berry
Brazelton, MD, Morris Green, MD and Robert Haggerty,
MD contributed to this emphasis. In 2009, the American
Academy of Pediatrics added Early Brain and Child Development as a major focus for the future.
Reach Out and Read is designed to operate in the special
circumstances of the medical setting and consists of three
linked interventions: the pediatrician (or other pediatric
primary care giver) gives each child a book purchased
with public and private dollars at each health supervision
visit from 6 months to 5 years of age. It is important to
note that the doctor gives the book as part of the visit.
This is not a book giveaway in which the child takes a
book on the way into or out of the office. The books are
chosen to be developmentally and culturally appropriate,
and as appealing as possible, with brightly colored pictures; board books are available for young infants, and
bilingual books are available where appropriate, and,
where possible, the pediatrician gives the parent developmentally appropriate anticipatory guidance about how
best to enjoy the book with the child, advising, for
example, that it is normal for a 6-month-old to mouth
the book immediately, but that the baby will enjoy
having the parent point to pictures and offer names, or
helping a parent understand that a 2-year-old may have a
short attention span, or may want to hear the same book
over and over. Clinicians also emphasize that reading
aloud is fun and stimulates language development, and
literacy-enriched waiting rooms include a range of
enhancements ranging from volunteer readers in clinic
waiting rooms who read aloud to children while they are
waiting for their visits (thereby modeling techniques of
reading aloud for parents), book shelves with books, and
small chairs and tables so children can look at books by
themselves or with their mother, posters, videos, etc.
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Table 1 SAFER strategies for literacy guidance
S
A
F
E
R
Show the child the book early in the visit
(do not wait until the end)
Share (look at or read) the book with the child yourself,
modeling for the parent
Ask the parent about reading aloud (‘Have you started
looking at books with Jane yet?’)
Assess the child’s development and the child–parent
relationship
Give feedback about what you have observed the child do
Give feedback about parents’ attitudes and interactions
with the child
Encourage the parent to read aloud daily to the child
Explain the benefits
Refer (to the library or family and adult literacy programs)
Record in the chart what you did
Reproduced with permission from [44].
The distinction between a book-giveaway program (‘take
a book on the way out’) and a clinical intervention of
modeling and advice by the physician is emphasized to
physicians receiving training in Reach Out and Read.
Although brief (30 seconds to two minutes), engaging a
parent and child with a book is reported by pediatricians
to be a pleasurable and important teachable moment.
Specific clinic-based strategies [44] for best practice are
seen in Table 1.
We discovered that giving books to children changed the
whole pediatric visit experience for young children from
one of fear to one of pleasurable anticipation. Similarly,
observing different capacities of children with books at
different ages stimulates pediatricians to think in a more
developmental framework (e.g., when do children recognize letters or hold a book right side up, how many objects
or animals can they point to or name, and when do they do
so?). The clinician modeling reading aloud with a child
provides parents with an opportunity to observe another
adult with their child and to see that sharing a book
involves verbal responsiveness, which is very important
[45] to infants. For example; in response to seeing the
young child looking at an object or picture book, a
clinician can model by making a sound like ‘Ba’, the
clinician might respond ‘that is a baby’ and, for older
children, asking questions, pointing out pictures, and
responding to the child’s interest. The clinician can also
demonstrate, model and/or observe other age-appropriate
skills and parent–child interaction as part of developmental surveillance (Table 2). Even parents who are
illiterate can and do point to and name pictures in books,
thus creating the same language and positive emotional
environment as literate parents.
Evidence of effectiveness
All published studies on the effectiveness of ROR using
different outcomes, including blinded direct assessment
of language and the home, and from different investigators and sites are remarkably consistent, showing
positive benefits [46–58].
Parent behavior
Parents who received ROR had a higher likelihood of
reporting looking at books with their child or naming
‘looking at books’ as a reported favorite activity [47].
Similar findings were obtained from both a clinic for
residents [48] and one serving primarily Hispanic
families. In the latter clinic, implementing literacy advice
and giving books utilizing bilingual materials resulted in a
10-fold increase in the odds of parents reading to their
child three or more times per week [49]. Another study,
involving a home observation, demonstrated that more
ROR clinic encounters are associated with a richer home
literacy environment [56]. Finally, a multicenter assessment of Reach Out and Read, at 19 clinical sites in 10
states, found increased odds of reading aloud, reading at
bedtime, and increased ownership of picture books in
parents who were exposed to Reach Out and Read
compared with those not exposed [57].
Language outcomes
In addition to parental behavior change, investigators
began to examine the critical question of the potential
effects of Reach Out and Read on children’s development.
Does giving a book, along with advice about the importance of sharing books, at well child visits actually translate
into improved language and literacy skills? In a prospective
Table 2 Age-specific child and parent behaviors with books for physicians, modeling and/or observing
6–12 months
12–18 months
24 months
3 years and older
Child behaviors
Parent behaviors
Reaches for book
Puts books in mouth
Looks at pictures
Points when asked ‘where?’
Makes sound for some pictures
Joint attention
Names familiar pictures
Fills in words to familiar stories
Recites parts to well known stories
Joint attention
Can re-tell familiar stories
Begins to recognize some letters
Follows baby’s eyes
Follows baby’s eyes
Lets child control book
Asks ‘where is’ questions
Asks ‘what’s that?’
Relate books to child’s experience
Ask ‘what’s happening here?’
Let child tell story
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Reach Out and Read Zuckerman and Khandekar 5
study of low-income families, after an average of three
visits, parents read to their toddlers more frequently and
reported increased enjoyment of book reading. The
increased book reading was associated with higher scores
on tests of expressive and receptive vocabulary, even for
words not in the books being distributed [50].
Another study found that an increased number of ROR
pediatric visits is associated with higher receptive and
expressive language scores [46]. Of note, the scores of the
intervention group still fell below the national average,
underscoring the underlying challenges in place for this
high-risk population. In a comparison at two similar
inner-city pediatric practices, the children from the
ROR practice had higher scores on receptive language
and on a measure of home-reading environment [53].
Parent–physician relationship
There are also reports of other benefits from participating
in Reach Out and Read, for both families and pediatric
providers. Families in a continuity clinic for pediatric
residents who were given early literacy-related anticipatory guidance and a book were more likely to rate their
doctor as helpful, and were twice as likely to report
enjoyment in reading together compared with those
who were only given the anticipatory guidance. The
pediatricians in this intervention group were also more
likely to rate parents as receptive than those in the group
that gave anticipatory guidance alone [52].
In a qualitative study from one ROR clinic serving a
large Spanish-speaking immigrant population, providers
encouraged parents in Spanish to ‘look at books’ with their
children and opened an on-site children’s library which not
only lent out books but held story-time and provided
community literacy resources in addition to giving bilingual books and advice. This clinic received 133 thank you
notes spontaneously during 1 year. The notes thanked the
clinic for the books and for running the library, expressed
benefits such as motivating children to read and to come to
the clinic, and revealed positive perceptions of the clinic
staff, for example ‘respect for the family’ [58].
Reach Out and Read: critical components for
success
Reach Out and Read is a relatively simple, inexpensive
and low-technology intervention, which is implemented in
over 4000 clinical sites reaching 32% of children below the
poverty line in the United States. There are 32 regional
coalitions nationwide that help raise funds and provide
training and support for local sites. Reach Out and Read
has received federal funding for almost 10 years with
additional support coming from 12 states and private
individual and corporate donors. There are special
coalitions for American Indians and military families.
ROR or adapted versions are practiced in over 11 countries
from Italy, Israel and Ireland to Africa and El Salvador.
The following critical factors contributed to ROR’s successful growth [1]: first, it was an innovation to address a
problem identified in primary care of low-income children.
Second, the innovation was simple and made common
sense. Third, support and dissemination occurred at a
grass-roots level. The ‘early adapting physicians’ and
physician champions were passionate about the importance of helping children have books in their home and
parents reading to them. Not surprisingly, reading to their
children was a specially valued activity of these physicians,
and their support had a strong base in equity between their
children and their patients. Fourth, data was generated to
support its effectiveness. Fifth, communication about the
intervention through published articles, Grand Rounds,
continuing medical educating courses, and stories in
pediatric media made it possible to reach early adaptors.
Sixth, nonphysician community volunteers helped provide
needed service and donors, and public officials, specifically
First Lady Hillary Clinton and Senator Ted Kennedy,
provided leadership to ensure federal and philanthropic
funds to help purchase books.
Conclusion
Reach Out and Read represents a special effort in which
evidence about the importance of reading aloud to young
children was applied to pediatric practice. The future
includes further expansion to reach all high-risk lowincome young children, quality improvement efforts to
ensure advice and books are given by physicians to all
children under 5 years at their well child visits, and finally
the adaptation and evaluation of related evidence-based
strategies to promote more effective reading aloud, interactive reading, designated books emphasizing rhymes to
enhance learning sounds, as part of Reach Out and Read
to enhance effectiveness of children learning to read.
Acknowledgement
This work is supported in part from the Maternal and Child Health
Bureau (MCHB) Training Grant.
References and recommended reading
Papers of particular interest, published within the annual period of review, have
been highlighted as:
of special interest
of outstanding interest
Additional references related to this topic can also be found in the Current
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